Health Share of Oregon: A Community-Oriented Approach to Accountable Care for Medicaid Beneficiaries.Health Share is a nonprofit founded in 2012 to coordinate the provision of medical, dental, and behavioral health care for Medicaid beneficiaries in a tricounty region encompassing Portland. As one of 16 coordinated care organizations designated by the state to oversee and improve the delivery of these services for a geographically defined population, it receives a global budget. It distributes per-capita payments to health plans—some of which are integrated delivery systems—and county-run mental health agencies that have agreed to accept risk for providing or ensuring access to defined services. These risk-bearing entities—all founders of Health Share—serve on its governing board, along with representatives of community-based organizations and social service agencies committed to this population. Health Share brings these stakeholders together to improve care for high-need, high-cost patients; achieve efficiencies by centralizing certain administrative and enrollment functions; and create accountability for performance. See more in this series.
The Colorado Beacon Consortium: Strengthening the Capacity for Health Care Delivery Transformation in Rural Communities. The Colorado Beacon Consortium was one of 17 regions that participated in the three-year, federally funded Beacon Community Program, which demonstrated how strengthening local health information technology (IT) infrastructure can support improvements in the quality and efficiency of health care. The consortium sponsored a learning collaborative and coaching for 51 primary care practices in seven predominantly rural Colorado counties, helping them to build capacity for using electronic health records and analytic tools and for engaging in team-based quality measurement and improvement. The region’s experience with health IT also offers insights on how community stakeholders can help spread health information exchange to improve care coordination among local "medical neighborhoods" of health care providers. See more in this series.
The Visiting Nurse Service of New York's Choice Health Plans: Continuous Care Management for Dually Eligible Medicare and Medicaid Beneficiaries. The Visiting Nurse Service of New York created a managed care plan serving lower-income, vulnerable patients enrolled in a partially capitated Medicaid Managed Long-Term Care program or a fully capitated Medicare Advantage Special Needs Plan, or both. Every health plan member is assigned a care manager who collaborates with an interdisciplinary care team and the member’s primary care physician to enhance access to appropriate services, improve care coordination and transitions, and promote optimal health outcomes and independent living. Other key components of the model include comprehensive member assessments, patient and family education, transitional and palliative care provided by nurse practitioners, and the use of risk stratification, information technology, and staff training. Over time, Medicare plan members have experienced fewer hospital admissions, readmissions, and emergency visits. The health plan's experience should inform organizations and policymakers interested in integrating care for patients with special needs. See more in this series.